Title:Helping in Haiti

How Georgetown is addressing the needs of people living with HIV who may slip beyond the reach of the health system

Given security concerns, staff in Haiti are referenced by first name only.

Amid an escalating humanitarian crisis in Haiti, access to health care has been severely compromised. With nearly 200,000 people displaced from their homes and communities, out of a total population of nearly 12 million, the provision of basic health services presents an urgent challenge. For those living with HIV, losing access to life-saving therapy can lead to unnecessary suffering, risk of transmission to others, and possible early death.

Physician Rachel understands this challenge all too well. As the Haiti country director for the Center for Global Health Practice and Impact at Georgetown University Medical Center, she has overseen nearly 160 health care workers and other staff members country-wide who are working to connect Haitian residents with HIV medications and to understand additional needs of those living with the disease.

Namely, they seek to understand why people discontinue treatment and how to better reach those who—for a variety of reasons—may slip beyond the reach of the health system.

Working amid significant political instability, poverty and violence, the Haiti-based team has become expert in adaptation. Criminal gang activity means the ability to move about freely in certain neighborhoods can change by the day, Rachel says, forcing the community health workers on her team to continually recalibrate their plans.

“Earlier on, before things got as bad, we could just drive from one site to another, but now we need to take a plane just so we don’t expose our people to the possible danger on the roads,” says the doctor, who started her career as a pediatrician. “The violence is impacting the way we do our operations, as we need to be thinking about where kidnapping or other issues could take place.

Turning the TIDE

With an estimated 150,000 people living with HIV, Haiti has the highest prevalence of HIV/AIDS in the Caribbean region. Of those infected, nearly 80% are on antiretroviral therapy, a cocktail of drugs that is prescribed by a health care provider. While there is no cure for HIV, antiretroviral therapy is highly effective at suppressing the virus and preventing further transmission.

A central challenge for the government’s efforts to maintain epidemic control is ensuring people continue taking their medications long term. While Haiti’s health system has done well in getting people screened and diagnosed, keeping people in the system to receive consistent care has proven difficult, according to Deus Bazira, director of the Center for Global Health Practice and Impact, and inaugural director of the Georgetown University Global Health Institute.

“In global health, access is always the number one challenge we are trying to solve,” he says. “Haiti could not really control the virus as long as people kept dropping out of care and stopped taking their medications, then becoming infectious to others.”

In 2019 and again in 2024, the U.S. Centers for Disease Control and Prevention (CDC) awarded Georgetown funding to implement the TIDE (Translating Data Into Evidence) project—and explore a deceptively simple question.

“Once you’ve gone through the hardest part, finding out your status, and you go on medications that we know are effective, why would you stop your treatment?” Bazira asks.

Bazira says the team initially surmised that poor nutrition, high transport cost to facilities, and low patient health literacy would surface as the main barriers in their research. Yet, after conducting focus groups and interviews, the prevailing obstacle was the inconvenience of accessing treatment.

“What we heard is that, ‘Where I need to go for treatment is very far away from my workplace and my home, and I’m not going to get time off.’ Or, ‘Then I have to go line up at the health facility for five hours to pick up my treatment,’” he says. “‘Especially if I feel okay, why would I miss a day at work to go and pick up drugs? This clearly showed that the service delivery system did not align with people’s lifestyle context or their individual circumstances.”

TIDE comprises three arms. The first entails generating data about the clients who interrupted their treatment to gain a full picture of the problem. The second involves partnering with associations for people living with HIV, civil society organizations, and the LGBTQIA+ community to identify community-driven solutions. And the third arm is setting up drug dispensing points that allow people to access their medications outside the confines of the conventional health system.

To date, Georgetown has helped organizations identify and set up 50 drug-dispensing points that serve nearly 10,000 beneficiaries nationwide. All the points are designed to be low-cost, low maintenance, and in line with quality assurance protocols developed in partnership with the Ministry of Health.

“Through the drug-dispensing points, we are making drugs more accessible, so people can access treatment in their own communities. It could be at a church, or a supermarket, or a private pharmacy,” says Rachel. “What matters is that they can access their medication how and where they want.”

Even in the midst of the ongoing violence that caused clinics to close their doors, 94% of the drug dispensing points were able to remain open, enabling clients to pick up their medications while other options were unavailable. Because internal migration is common due to instability, TIDE also has a hotline clients can call if they need to leave their community to find alternative access points.

People at the center

Fundamentally the project is about “supporting a lifestyle where the client can be themselves and be accepted,” according to Marie Ange, R.N., project director for one of TIDE’s projects known as PEARS (Peer-led Engagement for Assured Retention and Support). “We are offering a platform where the client’s voice can be heard, and we are promoting a people-centered approach where everything we implement, we do in collaboration with the beneficiaries.”

TIDE is implemented day-to-day by Haitians who understand the challenges and context of their own country best. Roughly half of the staff is made up of Haitians living with HIV/ AIDS, a factor which helps greatly with building trust and removing barriers related to fear of bias and discrimination.

In addition, TIDE has designed a web app where clients can provide their feedback on quality of services. Beyond the convenience factor, clients often cite feeling judged or otherwise uncomfortable as reasons why they opt to not pick up their medicine at a designated clinic.

Interacting with project staff who can relate to their circumstances makes a difference.

“We talk a lot about stigma and discrimination, but we can say we walk the talk by having an environment that is free of stigmatization,” Marie Ange says. “If we can provide opportunities for clients to spend less time in a clinic, it allows them to face less discrimination and to do other things they need to do beyond spending a day at a facility.”

Making the drugs more widely accessible also helps combat stigma, according to Bazira. If you need to pick up your drugs, you don’t have to go someplace that is known to be an HIV drug-dispensing point.

“You can walk into your community pharmacy just like anyone else who has to pick up any other drug,” Bazira says. “And we have trained the pharmacists so they understand and maintain the need for confidentiality and privacy. Pretty soon, word of mouth spreads that these are welcoming places to go.”

Building resilience

At a time when Haiti is battling skyrocketing unemployment and poverty, a critical element of TIDE’s work in the community is to strengthen people’s economic prospects. Staff members work with clients and the private sector to establish mutual solidarity networks, enabling people to put their money together into business cooperatives.

“People sometimes see HIV clients as sick people who cannot work or provide for themselves—this is not true,” Rachel says. “It allows clients to see themselves differently too.”

As the work can be grueling, especially for the more than 80 community health workers spread throughout the country, Georgetown’s team takes every opportunity to prioritize staff wellness and morale-building activities. Even small efforts can make a big difference for staff, says Rachel.

For example, they maintain a staff WhatsApp group where people can share their challenges and successes, and discuss the latest safety information. They also have a “corner of appreciation” to celebrate staff accomplishments, and they organize social gatherings to celebrate holidays, watch sports, or engage in other non-work activities. Every other week, the team holds learning sessions devoted to wide-ranging topics that are pre-selected by the staff.

These efforts recognize that, while clients are the focus of the TIDE project, the office staff and community workers are also living through a challenging time.

“Our team is really flexible and really resourceful—we have to be,” says Marie Ange. “It’s really hard at this time, so we look for strategies to help us stay focused on our goals.”

Far-ranging impacts

Building on learnings from the work in Haiti, Bazira’s center has secured funding from the CDC to pilot a new initiative at five hospitals in the southern African country of Eswatini. They have installed machines in the hospitals to dispense drugs, not just for HIV but also for hypertension and diabetes.

“This has enhanced convenience for people, who receive reminders via text, then just show up at a facility with a PIN, type it in any time of day, and can pick their drugs up and go,” says Bazira, also noting the added benefit of reducing the workload of health care workers.

While health outcomes are similar between those using the automated machines and those obtaining drugs through clinics or pharmacies, Bazira says “We are seeing better results [with the machines] around satisfaction from both patients and providers, and obviously the costs of providing care are much lower if you automate the system.”

Also stemming from the Haiti work, Georgetown researchers are refining a model that helps them predict the vulnerability of different populations based on certain socioeconomic characteristics.

“Beyond traditional demographic information, we look at social support systems and how people interact with their environment,” Bazira says. “Using that data, we help health care providers proactively come up with interventions that will prevent people from falling through the cracks,” Bazira says.

Real-world context

Through projects such as TIDE, Georgetown is advancing a discipline called implementation science, which at its core aims to deploy strategies that can best lead to the uptake of evidence-based treatment, such as HIV antiretroviral therapies, by those who are hardest to reach.

“While 90% of the people may have been reached successfully with a health intervention, there are always going to be what we call the ‘last mile’ —those who do not do well with those population-level interventions,” Bazira says.

This type of research entails a holistic view—looking not just at people’s medical status but their entire lived experience, including their environment, socioeconomic status, home life, religious beliefs, and more.

“This requires that we study these interventions in the real world, and not in a controlled research setting,” Bazira says.

Jiaqin Wu (G’24), a master’s candidate in the Data Science for Public Policy program at the McCourt School of Public Policy, works with the Center for Global Health Practice and Impact as a data scientist assistant. In his role supporting the Haiti data team with the development and refinement of the predictive model, Wu has developed a keen interest in the power of data to affect health policy.

“The data will tell you everything you want to know about when people are diagnosed and how they are doing with treatment,” Wu says. “But it’s our job to tell the machine what kind of data we need, to sort and clean the data, and ensure we have all the relevant variables, to help inform governments in their policy decision making.”

Wu is also interested in data visualization, which he views as essential to being able to use data effectively for advocacy purposes with a range of audiences. His work on the Haiti project has inspired him to pursue a career in public health when he graduates in May.

“Health is so important,” Wu says. “But people are more than just their diseases, and data helps us look into other aspects of their lives that will affect their health.”

The complexity of working in Haiti is indicative of where global health is heading, Bazira says. The world is seeing more refugees, more internally displaced persons, more conflict, and more climate-related disasters, among other crises. The ability to adapt to rapid change—and approach challenges with curiosity and an appreciation for people’s entire lives—is critical for success.

“Increasingly, these are the environments we’re going to find ourselves working in,” says Bazira. “As faculty we need to ensure our research and teaching reflect and capture this complexity. This is how we will help our students emerge as the future health leaders who are equipped to solve these problems.”

Editor’s note: Since Georgetown Magazine went to press, the U.S. Centers for Disease Control and Prevention and the President’s Emergency Plan for AIDS Relief awarded Georgetown $27.5 million to expand its ongoing work in Haiti to address HIV/AIDS. Read more >